Author Names
Milne, N. , Longeri, L. , Patel, A. , Pool, J. , Olson, K. , Basson, A. , Gross, A.
Reviewer Name
Sophia Razzi, SPT
Reviewer Affiliation(s)
Duke University School of Medicine Doctor of Physical Therapy Division
Paper Abstract
Purpose: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use. Design: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021. Participants: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition. Intervention: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored. Method: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach. Results: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition. Conclusion: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Through the synthesis of 87 articles, it was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population.
Key Finding #2
Although there is insufficient evidence to support the use of spinal mobilization and manipulation in addressing many pediatric diagnoses, it was determined that there is strong to very strong evidence that proposes that these interventions are not beneficial for managing headaches, nocturnal enuresis, and asthma in the pediatric population.
Key Finding #3
There is a great need for high-level RCTs to determine the risks and benefits of spinal mobilization and manipulation in the pediatric population.
Please provide your summary of the paper
This systematic scoping review synthesized the findings of 87 articles to determine the effects of spinal manipulation and mobilization in the management of various pediatric conditions such as adolescent idiopathic scoliosis, asthma, ADHD, ASD, back/neck pain, breastfeeding difficulties, dysfunctional voiding, CP, headaches, excessive crying, infantile colic, nocturnal enuresis, kinematic imbalance due to suboccipital strain (KISS), otitis media, plagiocephaly, and torticollis. It was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population for the majority of conditions examined; however, there is strong evidence that these techniques are not effective in managing headaches, nocturnal enuresis, and asthma. Additionally, four systematic reviews included in this article outlined the adverse effects of utilizing spinal manipulation and mobilization in the pediatric population and these adverse events ranged from mild (e.g. muscle soreness) to severe (e.g. death). More research needs to be conducted in this area to determine the risks and benefits of the use of this intervention in the pediatric population.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Due to the fact that the majority of the literature examining the effects of spinal manipulation and mobilization in the pediatric population is established on the basis of low-level studies (e.g. case reports), their findings are unable to be generalized to larger populations. However, the findings of these studies do outline various safety concerns that should be taken into account in clinical practice. Due to the lack of research as well as reported risks, the majority of clinicians may not feel comfortable utilizing spinal manipulation or mobilization in pediatric clinical practice. However, if through more research it was determined that spinal manipulation and mobilization are effective in the treatment or management of various pediatric diagnoses, thorough medical screening would be warranted to determine the presence of underlying pathologies that may lead to a contraindication of these techniques. It is evident that additional research must be conducted prior to the widespread implementation of spinal manipulation and mobilization in pediatric clinical practice.
